Failure to Coordinate Hospice Medication Orders on Admission
Penalty
Summary
The facility failed to effectively collaborate and communicate with hospice representatives to ensure a resident received prescribed glaucoma medications upon admission. The resident, admitted for hospice respite care, had a documented history of primary open-angle glaucoma and was taking three specific eye drop medications at home, as detailed in her preadmission home health paperwork. Despite this information being uploaded into the facility's medical record prior to admission, the medications were not included in the initial hospice orders written at the facility, and the resident did not receive these medications for several days after admission. Interviews revealed that the admitting nurse did not review the medication reconciliation list available in the resident's electronic medical record, relying instead on verbal instructions from the Admissions Coordinator and the hospice nurse. The hospice nurse, in turn, based her medication orders on the medications physically provided by the resident and did not consult the preadmission medication list. The resident and her family reported that the eye drops were brought to the facility and given to staff, but the medications were not administered until several days later, after the issue was discovered by facility leadership. Facility leadership, including the DON and DNS, stated that their process was to follow the orders written by the hospice nurse and not to reference the preadmission medication reconciliation list unless questions arose. The contract between the facility and hospice required joint development and agreement on the plan of care, but in practice, the facility deferred to hospice for medication orders. This lack of coordination and communication resulted in the resident missing several doses of her prescribed glaucoma medications immediately following admission.